Letters from Maine

Fumbled handoffs


 

A century ago, when solo practitioners walked the earth and practiced in offices that often doubled as their homes, patients expected that when they called their doctor, they would talk to and see their doctor, not some stranger who claimed he or she was a physician. Doctors seldom took much time off nor did they keep terribly voluminous records. Vital signs, immunization dates, and demographic data were documented. Lab work was rarely ordered and therefore rarely recorded. They scribbled notes simply to jog their memory. Most isolated solo practitioners saw little reason to keep extensive notes. In the very rare circumstance that a physician might be away, the covering physician would see patients in his or her own home or office and not have access to the records.

But time has marched on. The population has grown and clumped together in cities and suburbs. Physicians banded together into groups to allow themselves more free time. Initially, these were merely coverage arrangements, but eventually, members of the group were housed under the same roof.

For the patients, this evolution meant trade-offs. Groups meant that there was always a physician on call and responsible for their care. However, it meant becoming accustomed to often seeing an unfamiliar face. As electronic health records have become more prevalent, the chances are greater that a covering physician is going to have instant access to a patient’s medical record. This availability should provide some comfort to the patient seeing a strange physician. But medical records are typically rather cold and impersonal documents that do little to warm up a new and temporary professional relationship.

In the hospital setting, this transition from primary to covering physician is often referred to as a "handoff," and is best done as a "warm handoff" in the presence of the patient with handshakes and introductions. Obviously, this kind of transition is neither practical nor possible for the run-of-the-mill outpatient. However, for the complex case or when the parents or I are more than a little concerned, it can be very comforting to all if I can walk them down the hall and briefly introduce them to the physician who will be covering until I return. It takes time, but it is time well spent.

However, most of the time a warm handoff isn’t possible. There are other options, and this is where I think many of us could do a better job in making our medical records into what might be called living documents. There is only so much information one can convey with check boxes and templates. This is particularly true in situations in which we have discussed a Plan B or C with the family. I find that too often a physician may have told the family "if this doesn’t work I’m going to prescribe antibiotics," or "order this test" ... and then neglects to document that discussion.

I think we must be careful not to present our Plans B’s as promises to the family because they can tie the hands of the covering physician should the situation change. However, in most cases the primary physician’s plans are appropriate, but it is discomforting for the family and embarrassing to the covering physician when these discussions haven’t been documented.

In situations in which a warm handoff can’t happen or there is some uncertainty whether the medical records will be available, I know it’s old fashioned, but a short phone call to the covering physician is courteous and good medicine. The family appreciates it when they can hear, "Dr. Primary called yesterday and told me that you might be calling today."

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine.

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